A Qualitative Study of Participant Engagement With a Weight Loss Intervention

Study Setting

This qualitative study was conducted in general practice in the London Borough of Camden in association with the CAMWEL RCT, which recruited 381 adults from 28 practices with BMI ≥25 kg/m² and randomly assigned them to the intervention (n = 191) or control (n = 190) group. The study was approved by the London School of Hygiene & Tropical Medicine Ethics Committee, the Camden and Islington Community Research Ethics Committee (Reference No. 09/H0722/22), and the North Central London Research Consortium.

The Intervention

The intervention took a long-term approach to behavior change for weight loss and was based on tailored one-to-one advice sessions with a trained advisor. The participants were invited to attend 14 sessions over a 12-month period. The program was delivered in three primary care centers and compared to a control group receiving usual care in general practice. The CAMWEL program (Nanchahal et al., 2012) combined evidence-based components recognized as essential for behavior change and successful weight loss (Jones & Wadden, 2006)—healthier eating advice, how to increase physical activity in everyday lifestyles, tailored goal setting, keeping food and activity diaries, self-monitoring, positive reinforcement, coping with lapses and high-risk situations, and long-term support. The CAMWEL program used theoretical frameworks such as social-cognitive theory, outcome expectations, self-efficacy, self-regulation, diet, and physical activity monitoring that underpin health promotion interventions that have an emphasis on long-term changes in habits. As participants progressed through the program, the frequency of meetings with their advisor decreased. The CAMWEL weight loss advisors were trained in the principles and techniques behind behavior change including social-cognitive theory, goal setting, motivational interviewing, counselling approaches, and systems thinking in their initial 2-day training course, and used these techniques in each session of the program. The full trial methodology and results are reported elsewhere (Nanchahal et al., 2012).

Qualitative Study Design and Sample

The qualitative data collection was composed of semistructured face-to-face interviews with CAMWEL intervention participants and a focus group with additional intervention participants who had successfully achieved their 5% weight loss goal after their halfway 6-month follow-up appointment. For the interviews, 18 participants from the intervention arm of the CAMWEL RCT (9.4% of all intervention participants) were recruited and were interviewed by AS up to three times over the course of the 12-month intervention period. We used a purposive sampling strategy to include a mixture of participants by age, gender, ethnicity, and BMI. A total of 37 interviews were conducted with the aim of discussing their experiences of taking part in the trial (Table 1). Interview participants’ characteristics were comparable to all intervention participants except a higher proportion of interviewees were employed (Table 2). The interviews lasted approximately 30 minutes and were audiotaped with participants’ permission. For the focus group, all eligible participants (n = 35) were invited to take part by letter, and a convenience sample of five were recruited. The group discussion was convened by the research team, and ran for 90 minutes. Participants were given £15 shopping vouchers as compensation for their time.

OPEN IN VIEWER

Table 1

Topic Guide for Semistructured Interviews

Theme	Questions/Prompts
Participation in the study (only for first interview)	● When did you first hear of the weight management study?
	● When did you first hear of the CAMWEL study?
	● What were your first thoughts when you learned about it?
	● How did you feel about your weight before this?
	● What was your main reason for deciding to take part?
	● Had you thought of taking action with regard to your weight prior to this?
	● What are your hopes for taking part in the study?
The intervention	● Who is your health advisor?
	● When was your last session?
	● What happened in that appointment?
	● Have you had to miss any appointments?
	● How do you find the timing of the meeting? Length and frequency?
	● How do you feel about the health advisor? Are they helpful? Is there anything they could do differently?
	● What do you think of the leaflets/handouts you are given in the study?
Acceptability	● What do you think/how do you feel about the weight management program?
	● What aspects do you like best?
	● What aspects do you like least?
	● Are you satisfied with what has happened with your weight since starting the program?
	● Has the program met your expectations?
	● Are there things you would change about how it is delivered or experienced? If so, what?
Generalizability	● Would you recommend the program to a friend? Why or why not?
Impact	● Has your lifestyle changed since starting the program? If so how?
	● How do you feel about your weight at the moment?
	● Has this changed since you started the program? If so, in what ways?
	● Has your weight?
Follow-up questions	● Have you changed the amount of weight that you’d like to lose? Why?

NOTE: CAMWEL = Camden Weight Loss.

OPEN IN VIEWER

Table 2

Baseline Characteristics of CAMWEL RCT Intervention Participants Compared to Qualitative Study Intervention Participants

	CAMWEL RCT		Qualitative Study Sample
Characteristics	%	n	%	N	p
Allocation: Intervention	50.13	191	9.4	18
Age group (years)
18 to <35	20.9	40	5.6	1	.32
35 to <50	31.4	60	44.4	8
50 to <60	24.1	46	22.2	4
≥60	23.6	45	27.8	5
Body mass index (kg/m2)
25 to <30	25.6	49	27.8	5	.82
≥30	74.4	142	72.2	13
Gender: Female	71.7	137	61.1	11	.29
Ethnicity: White	74.2	124	88.9	16	.08
Education: No qualifications	8.8	15	11.1	2	.66
Employed: Yes	63.2	108	33.3	6	.03
Area deprivation (IMD): Lowest quartile (deprived)	23.9	45	11.1	2	.18
Lost 5% of initial weight	18.3	35	22.2	4	.52

NOTE: CAMWEL = Camden Weight Loss; RCT = randomized controlled trial; IMD = index of multiple deprivation.

Data Analysis

All interviews and the focus group discussion were recorded and transcribed verbatim. A thematic analysis (Braun & Clarke, 2014) was undertaken by EH and NT. Transcripts were initially reviewed independently for emergent themes and concepts and then coded against these themes using qualitative data analysis software (NVivo). These initial findings were discussed by all authors over several meetings to agree the main themes, and all authors participated in the interpretation of the results.

The Advisor–Participant Relationship

For many participants, the relationship they formed with their advisor was the most important aspect of the program. Regular meetings with a trained advisor in a confidential health care environment was seen to correspond to the therapeutic relationship of a counseling setting. Our data suggest that, regardless of the weight loss outcome, it was this regular, consistent, individually tailored, one-to-one relationship with an advisor that participants valued (n = 17/18 endorsed this theme).

I said before, it’s knowing that you’re going to come and see someone every two or so weeks to talk about it and, you know, tell them your shortfall and where you might think you’ve gone wrong, you can probably do better and also change this and that. That’s the most important thing. (Man, 43, interview 1/1)

The meetings provided participants with more than monitoring progress in weight loss terms, and advisors were sources of empathy and unconditional positive regard:

I get solace here . . . [Advisor] lets me off-load my guilt and, you know, to me it’s much more about you’re going to have to do it yourself so it’s more there as a support, you know, I see him once every now two, now three weeks, you know, there’s no way I can rely on him to do it for me. (Man, 42, Interview 2/2)

For some participants, it was the first time that anyone had invested attention and interest in their lives and the intervention became “lifestyle management,” rather than just an attempt at weight loss:

No one’s ever spent, had that interest in my life . . . . it became a bit of lifestyle management which, you know, you just don’t ever get. (Man, 43, focus group participant)

Participants sought understanding and compassion from their advisor about aspects of their day-to-day lives apart from their weight loss effort, and some explained how their wider life experiences interacted with their weight loss progress and ability to attend meetings:

[Of her husband] I’m his carer, really. Like if anything goes wrong with him, I’m the first one that’s got to be there if anything happens, I can’t even leave him. (Woman, 62, interview 2/2)

The few times I had to cancel I was working hard to get ready for the craft fair . . . and my ceiling collapsed. (Woman, 37, interview 2/2)

Having sessions with the same person was important, to build a relationship and strong working alliance. As a result of the relationship, an accountability to the advisor was possible that would not have been with inconsistent personnel.

I think the point was that it’s the same person there . . . had it been a machine on its own I would have been motivated to a point but not that much of a point, whereas if it’s a different person every time . . . that wouldn’t have been as effective, but if it’s the same person . . . (Man, 43, focus group participant)

My counselor did leave, and I’d have preferred my counselor to stay obviously . . . I wouldn’t say it’s quite the same . . . It’s ‘cos you’d like to see it through together almost. (Woman, 51, focus group participant)

Program Structure

The structure of regular meetings with the advisor provided routine for participants and acted as a framework for their weight loss effort. The frequency and regularity of sessions during the early phase of the intervention were regarded as an important mechanism in maintaining the lifestyle changes participants were making and in keeping them “on track” to achieve their weight loss goal. With the next session due in 2 to 3 weeks, participants felt that they were being “monitored” and that they would not have had time to “slip up” and reverse any good habits that had been formed before their next session (n = 14/18).

There was no escape; I knew it was coming up so I got back on track. So that does help . . . having someone . . . where your own willpower falters occasionally, you have this power overlooking you. (Man, 42, interview 2/2)

I’m a bit slow about losing weight, but it’s the fact that someone’s going to weigh me, that is a constant reminder. (Woman, 53, interview 2/3)

However, participants were critical of the change in regularity in the later phase of the intervention when meetings with the advisor became less frequent.

You have to look at any slimming club. They have regular meetings once a week because they actually know that those people, people like us, need regular control. (Woman, 37, interview 2/2)

Participants who had not yet switched to less frequent meetings but who were anticipating them in future were anxious about the change, as they had become accustomed to regular monitoring.

Fortnight’s good. I’m worried about later on. The gaps in-between. (Woman, 56, interview 1/2)

But then it goes I think to three weeks. I’m a bit more concerned that three weeks may not be a good idea . . . . I get too relaxed. (Woman, 53, interview 2/3)

Perceptions of Trial Materials

The sessions were supported with tangible materials (e.g., leaflets, a pedometer, and portion pots) that were distributed to participants via their advisors. The purpose of the materials was to provide the participant with a motivator between sessions, and the leaflets were a record of what had been discussed during the sessions. Some materials were liked more than others, such as the pedometer (n = 12/18).

The scheme has thrown up some useful tools, like the pedometer, I’ve got something to measure against. (Man, 63, interview 1/2)

Participants were impressed with the quality of the item:

It’s much nicer than the pedometers I’ve had before. (Woman, 31, interview 1/3)

The pedometer helped participants to monitor their activity in between sessions with the advisor, and the pedometer acted as a reminder that they were taking part in the intervention.

By wearing this, I sort of keep an eye on how I’m doing on a daily basis. (Man, 60, interview 1/3)

I wear the pedometer religiously every day, more as a reminder to me that I’m doing this. (Man, 42, interview 1/2)

Participants were asked to record their daily steps and daily food intake in a diary. This allowed them to self-monitor their activity and food intake and was intended as a goal setting and feedback (Locke & Latham, 2002) component of the intervention program; however, both diaries were regarded as somewhat of a chore (n = 6/18).

I’ve filled in the forms for a period until the habit has been formed but . . . it’s a bit off putting the amount of recording you’ve got to do. (Man, 60, interview 1/3)

At each session, new topics were introduced with the help of generic leaflets and handouts. The leaflets were generally negatively regarded (n = 13/18), as it was often felt that they had heard the content before during previous weight loss attempts and that they offered no new information, and were considered patronizing by participants.

Those leaflets, I don’t know, it’s like we’re stupid . . . a lot of people know everything about weight loss yet we can’t maintain it. (Woman, 37, interview 2/2)

I mean, I think my wife has put them in front of me probably ten years ago, so I know most of the stuff. (Man, 42, interview 1/2)

I suppose they are targeted at the lowest common denominator. (Man, 42, interview 2/2)

Further materials included portion pots, and a “100 Calorie Kit,” which was devised by CAMWEL researchers as a visual aide to show participants what a 100-calorie portion of a variety of foods looked like. These materials provided visual representations and an objective perspective on portion sizes that some participants found particularly helpful (n = 5/18):

When I saw that, I was quite shocked because I was probably putting twice as many oats. (Woman, 37, focus group participant)

What was useful is . . . that knowing, the realization of the quantities which you never really quite accept until you see it and that is very eye-opening. (Woman, 67, focus group participant)

Limitations of the Study

Not all trial participants took part in interviews, and therefore the interviews may not be representative of the views of all participants. Those who did take part may not have completed all three interviews.

Conclusion

In lieu of wider policy changes to tackle the obesogenic environment in which we presently reside, improving the design of individual-level weight loss interventions is important. An individual-level weight loss intervention needs to be acceptable from the patient perspective in order to ensure that participants are engaged with the program for as long as possible to maximize favorable results. Reframing the problem of obesity as a chronic condition that needs long-term and possibly lifelong management is necessary.